New Jersey Administrative Code
Title 11 - INSURANCE
Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS
Subchapter 7 - CONTINUOUS QUALITY IMPROVEMENT
Section 11:24-7.3 - Performance and outcome measures

Universal Citation: NJ Admin Code 11:24-7.3

Current through Register Vol. 56, No. 18, September 16, 2024

(a) The Department shall develop a performance and outcome measurement system for monitoring the quality of care provided to HMO members. The data collected through this system may be used by the Department to:

1. Assist HMOs and their providers in quality improvement efforts;

2. Provide the Department with information on the performance of HMOs for regulatory oversight;

3. Support efforts to inform consumers about HMO performance;

4. Promote the standardization of data reporting by HMOs and providers; and

5. Any other purpose consistent with this chapter and 26:2J-1 et seq.

(b) The performance and outcome measures shall include population-based and patient-centered indicators of quality of care, appropriateness, access, utilization, and satisfaction. To minimize costs to HMOs, providers, and the Department, performance measures shall incorporate, when possible, data routinely collected or available to the Department from other sources. Data for these performance measures may include, but not be limited to, the following:

1. Indicator data collected by HMOs from chart reviews and administrative data bases;

2. Member and patient satisfaction surveys;

3. Provider surveys;

4. Quarterly and annual reports submitted by HMOs to the Department as specified in 11:24-3.7;

5. Computerized health care encounter data; and

6. Data collected by the Department for administrative, epidemiological and other purposes, such as the State cancer registry, vital records, and hospital UB-92 records.

(c) HMOs shall submit such performance and outcome data as the Department may request from time to time.

(d) The Department shall make, when appropriate, statistically valid adjustments to account for demographic variations among HMOs. Each HMO shall have opportunity to comment on the compilation and interpretation of the data before its release to consumers.

(e) The Department shall conduct audits of each HMO's performance and outcome data including desk and on-site audits.

(f) The Department shall conduct or arrange for periodic member satisfaction surveys. The HMO shall provide the Department with the member mailing list, upon request, to be used to select samples of the HMO's membership for the surveys.

(g) The Department shall ensure the confidentiality of patient specific information.

(h) The Department shall take all necessary measures to reduce duplicative reporting of information to State agencies.

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